Abstract
Background: There are concerns that chlorhexidine skin decolonisation may select multidrug resistant pathogens. We evaluated the effects of de-escalating from universal to targeted chlorhexidine decolonisation on Staphylococcus epidermidis bloodstream infections (SE-BSI).
Methods: We did a retrospective before-after control-impact time-series analysis and longitudinal genotypic study in two ICUs in Scotland. Participants were adults ≥16 years admitted between Jul 1, 2009, and Feb 28, 2022. In ICU1 (intervention site) universal decolonisation in all admissions was de-escalated to targeted decolonisation of high-risk MRSA carriers on Feb 1, 2019, while in ICU2 (control site) targeted decolonisation was applied throughout. We used multilocus sequence typing to identify sequence types (ST) from SE-BSI episodes. Whole genome sequencing was applied to a random sample from ICU1. The primary outcomes were i) all BSI incidence density, ii) MRSE incidence density, iii) probability that SE-BSI were meticillin-resistant. The effects of de-escalation on MRSE in ICU1 were estimated by differences between the intervention and control sites, before and after de-escalation.
Findings: There was no increase in all BSI incidence coinciding with de-escalation in ICU1. MRSE incidence during universal decolonisation increased more rapidly in ICU1 [2·3 (95% credible interval 1·4-3·5) and 10·9 (CI 7·2-15·4) MRSE cases per 1000 OBDs at the beginning of the study and immediately before de-escalation], compared to ICU2 [1·3 (CI 0·6-2·4) and 5·3 (CI 2·9-8·7) MRSE cases per 1000 OBDs]. De-escalation was associated with reduced MRSE due to epidemic multidrug resistant sequence types, increased susceptibility to chlorhexidine and reduced carriage of mobile genetic elements and genes for multidrug resistance and biofilm production.
Interpretation: In low MRSA incidence settings, de-escalation from universal to targeted chlorhexidine decolonisation may reduce selection of multidrug resistant S. epidermidis. ICU decolonisation practices should balance risks and benefits of biocide use and be informed by surveillance of sentinel infections.
Methods: We did a retrospective before-after control-impact time-series analysis and longitudinal genotypic study in two ICUs in Scotland. Participants were adults ≥16 years admitted between Jul 1, 2009, and Feb 28, 2022. In ICU1 (intervention site) universal decolonisation in all admissions was de-escalated to targeted decolonisation of high-risk MRSA carriers on Feb 1, 2019, while in ICU2 (control site) targeted decolonisation was applied throughout. We used multilocus sequence typing to identify sequence types (ST) from SE-BSI episodes. Whole genome sequencing was applied to a random sample from ICU1. The primary outcomes were i) all BSI incidence density, ii) MRSE incidence density, iii) probability that SE-BSI were meticillin-resistant. The effects of de-escalation on MRSE in ICU1 were estimated by differences between the intervention and control sites, before and after de-escalation.
Findings: There was no increase in all BSI incidence coinciding with de-escalation in ICU1. MRSE incidence during universal decolonisation increased more rapidly in ICU1 [2·3 (95% credible interval 1·4-3·5) and 10·9 (CI 7·2-15·4) MRSE cases per 1000 OBDs at the beginning of the study and immediately before de-escalation], compared to ICU2 [1·3 (CI 0·6-2·4) and 5·3 (CI 2·9-8·7) MRSE cases per 1000 OBDs]. De-escalation was associated with reduced MRSE due to epidemic multidrug resistant sequence types, increased susceptibility to chlorhexidine and reduced carriage of mobile genetic elements and genes for multidrug resistance and biofilm production.
Interpretation: In low MRSA incidence settings, de-escalation from universal to targeted chlorhexidine decolonisation may reduce selection of multidrug resistant S. epidermidis. ICU decolonisation practices should balance risks and benefits of biocide use and be informed by surveillance of sentinel infections.
| Original language | English |
|---|---|
| Publisher | Social Science Research Network |
| Number of pages | 36 |
| DOIs | |
| Publication status | Published - 13 Aug 2024 |
Keywords
- Staphylococcus epidermidis
- meticillin resistance
- bloodstream infections
- intensive care unit
- chlorhexidine decolonisation